Alliance Imaging Value PropositionYour Partner for Women’s Breast Health Care Solutions

Month Day, Year

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Meet Alliance Imaging

• With more than 25 years experience, Alliance Imaging is the largest provider of advanced outpatient diagnostic imaging services in the United States, focusing on MRI, PET/CT and CT. – We partner directly with hospitals and other healthcare providers

to develop fixed-site imaging centers, offer mobile services, introduce women’s breast health care solutions and more.

– Our comprehensive, turnkey solutions include market analysis, management and staffing, state-of-the-art technology, and marketing.

– We have more than 1,000 hospital and other healthcare customers in 45 states, and we operate more than 500 diagnostic imaging systems.

– We have approximately 2,300 team members across the country.– As a division of Alliance HealthCare Services, we provide cancer

center services through our sister division, Alliance Oncology.

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Mission, Vision & Values

• Our Mission – Who We Are– Our mission is to provide diagnostic imaging and radiation oncology

solutions, working in partnership with hospitals and physicians. We deliver exceptional patient care with unparalleled passion and commitment to ensure the very best healthcare for those we serve.

• Our Vision – Where We Are Going– Our vision is to be the recognized leader in specialized healthcare

services. Through our focus on quality patient care, customer solutions, and team member satisfaction, we will set the standard for a broad range of healthcare needs.

• Our Values – What We Believe– We are committed to being a customer-focused organization,

characterized by quality, innovation, integrity and ethics, respect, teamwork, and accountability.

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The Evolution of Women’s Health Care

“Healthcare organizations that organize and deliver Systems of CARE to provide services in the most cost-effective manner could be the winners in our new environment. The discussion is about organizing a service that has the following components integrated to exceed customer expectations: physicians, facilities, ancillary services, supplies and even patient ‘coproduction.’ We need to go from well-intentioned health systems, with everyone doing their part, to high-performing, aggressively orchestrated Systems of CARE.” – Sg2

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The Evolution of Women’s Health Care

OLD-FASHIONED PARADIGM

Conventional Care- outside of obstetrics and gynecology, little differentiation or marketing of services relating to women’s health

- knowledge of, attention to gender-based medicine highly dependent on individual physician

OLD-FASHIONED PARADIGM

Conventional Care- outside of obstetrics and gynecology, little differentiation or marketing of services relating to women’s health

- knowledge of, attention to gender-based medicine highly dependent on individual physician

THE NEW BASELINE

Differentiated Care

- select, specific services focusing on women’s health

- offerings may be scattered throughout

the hospital

- increasing attention to gender-based

medicine, though potentially limited only to differentiated services

THE NEW BASELINE

Differentiated Care

- select, specific services focusing on women’s health

- offerings may be scattered throughout

the hospital

- increasing attention to gender-based

medicine, though potentially limited only to differentiated services

THE VISION Distinctive Care

- separate, identifiable suite of centralized services dedicated to women’s health

- attention to gender-based medicine built into organizational model

- array of women’s health services may be limited except in centers of excellence

THE VISION Distinctive Care

- separate, identifiable suite of centralized services dedicated to women’s health

- attention to gender-based medicine built into organizational model

- array of women’s health services may be limited except in centers of excellence

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Alliance’s Vision:

Truly Comprehensive Women’s Breast Health Care

• In the United States today, close to 90 percent of breast health programs offer the basic menu of services shown above. A small percentage also have a breast health navigator and/or some risk assessment. But only a handful (45 to 50 centers total) provide truly comprehensive women’s breast health care.

• Breast centers with truly comprehensive care can detect cancer sooner through risk assessment, breast density evaluation, proactive intervention and advanced imaging. This enables treatment of cancer in its earliest stages, saving more lives.

• Does your breast center look like this?– Screening mammography– Diagnostic mammography– Focal point ultrasound– Stereotactic breast biopsy– Bone densitometry

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Women’s Breast Health Today

• Dense breast issue is seldom reported to patients– Density is always captured during a mammogram. However, its

importance is not always fully understood by the radiologist and rarely understood by referrers. Therefore, it is almost never reported to patients.

• Very few centers perform comprehensive risk assessment (45 to 50 in the United States)

• Breast health navigator only comes into play after diagnosis; no patient coordinator to guide and support patients on the front end of the care path

• Very few patient coordinator/physician consults• Lack of referring physician education/training concerning dense

breast issues• Report-oriented radiology paradigm instead of proactive

intervention/prevention

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Women’s Breast Health Today (cont.)

Referring physicianorders mammogramReferring physicianorders mammogram

Mammographycenter acquires

patient data

Mammographycenter acquires

patient data

Mammographicstudy performedMammographicstudy performed

Radiologist reads caseRadiologist reads case Creates reportCreates report

Some type of risk assessment is sometimes done, but no cohesive plan

Some type of risk assessment is sometimes done, but no cohesive plan

Radiologist reports are many timesinconclusive, not integrated

Radiologist reports are many timesinconclusive, not integrated

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Breast Cancer Care Path

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A Truly Comprehensive Approach

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Why Risk Assessment?

Utilization Growth PotentialScreening Mammography

Screening Ultrasound

Very High

Very Low

Low

High

Risk Assessment & Density Evaluation

Very Very Low Very High

Diagnostic Imaging High Low

Image-Guided Biopsy Moderate Moderate

Advanced Imaging (Breast MRI, etc.)

Low High

Surgery High Low

Reconstruction Moderate Moderate

Radiation Therapy Very High Low

Chemotherapy Very High Low

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• A comprehensive risk assessment program can help you:– Systematically evaluate patients at risk for developing breast

cancer or for having a breast cancer that forms under normal risk and is masked.

– Identify patients who are at risk and not being diagnosed today.

– By employing advanced imaging procedures, you can:• Detect more cancers• Find them sooner• Discover them when they are smaller• Potentially save more lives

Realizing the Potential of Risk Assessment

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• A comprehensive risk assessment program can help you: (cont.)– Quantify patients at risk for genetic mutations. Once you

know who they are, you can:

• Educate these patients• Help them make more informed decisions• Schedule appropriate monitoring and follow-up

– Quantify patients who don’t have the typical risk factors, but who do have a two to three times greater chance of having a cancer go undetected.

• 80% of women with breast cancer have no risk factors at all, other than density.

Realizing the Potential of Risk Assessment (cont.)

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10,000 patients were run through various risk assessment models. The chart below shows how many patients received a lifetime breast cancer risk of 20% or greater from each model.

Comparing Risk Assessment Models

Tyrer-Cuzick

330 (5.6%)

276 BRCAPRO25 (0.4%)

Claus54

(0.9%)

10 2

3113

0

10

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• Lack of education regarding the value of breast MRI– Many general MRI sites don’t want to deal with the challenges of

breast MRI• Perceived as difficult to read• Takes a long time to read• Reimbursement is approximately $99

• Lack of education regarding the value of screening ultrasound– Almost all breast centers do not offer screening ultrasound. – Incorrect perceptions:

• Too long to perform• Too many biopsies• No way to get paid

• Important: Once the concept of needs is communicated, the procedure (whether breast MRI or breast ultrasound) is an annuity. Since you identified the need, they will come back to you for the solution.

Why Comprehensive Risk Assessment is Rare

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• Lack of education regarding the value of risk assessment– Many sites have no comprehensive program.

• Challenges of implementation with systematic tools and processes– Don’t know what model to use– Some models are free, but require putting processes in place– IT tools and implementation required

• Lack of radiologist education; don’t see the need for clinical pathway paradigm shift

• Lack of referring physician education and understanding

Why Comprehensive Risk Assessment is Rare (cont.)

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• ACS guidelines for breast screening with MRI as adjunct to mammography:– Recommend annual MRI screening (based on evidence):

• BRCA mutation• First-degree relative of BRCA carrier, but untested• Lifetime risk of 20% to 25% or greater, as defined by

BRCAPRO or other models that are largely dependent on family history

– Recommend annual MRI screening (based on expert consensus opinion):

• Radiation to chest between age 10 and 30 years• Li-Fraumeni syndrome and first-degree relatives• Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-

degree relatives

American Cancer Society (ACS) Guidelines

GREENZONE

Breast MRI

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– Insufficient evidence to recommend for or against MRI screening:

• Lifetime risk of 15% to 20%, as defined by BRCAPRO or other models that are largely dependent on family history

• Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)

• Atypical ductal hyperplasia (ADH)• Heterogeneously or extremely dense breast on mammography• Women with a personal history of breast cancer, including

ductal carcinoma in situ (DCIS)

– Recommend against MRI screening (based on expert consensus opinion):

• Less than 15% lifetime risk

American Cancer Society (ACS) Guidelines (cont.)

GREYZONEBreast

Ultrasound

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• If 10,000 patients who have mammograms underwent a risk assessment and breast density evaluation, you could expect to perform:– Detailed planning and secondary screening for approximately

4,000 women*– An additional 2,000 to 4,000 whole-breast ultrasound studies– An additional 350 to 400 breast MRIs– Twice the amount of physician consults and follow-up visits

• Numbers may vary slightly based on population estimates.

What This Means for You

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• A comprehensive risk assessment program benefits your business by:– Differentiating your center with a unique advantage over

competitors– Keeping patients in your system– Attracting patients’ family members– Securing breast MRI every year for life, for those patients

with a lifetime risk of 20% or more

– Adding other modalities, tests and procedures to your services– Improving insurance authorizations

What This Means for You (cont.)

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ACR BIRADS Scale for Breast Density

1

ALMOST ENTIRELY FATTY:Mammogram very effective, sensitive

to even small tumors

© Mayo Foundation for Medical Education and Research. All rights reserved.

2

SCATTERED FIBROGLANDULA

R TISSUE:Minor decrease

in sensitivity

3

HETEROGENEOUSLY DENSE TISSUE

PRESENT:Moderate decrease

in sensitivity

4

EXTREMELY DENSE TISSUE

PRESENT:Marked decrease

in sensitivity

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• Women with dense breasts are five times more likely to develop breast cancer. Source: American Cancer Society

• Those cancers are two to three times more likely to slip by a radiologist reading a routine mammogram. (Cancerous lesions appear white on a mammogram, but dense breast tissue also appears white – a situation that can camouflage malignancies.) Source: JAMA. 299(18).

• Close to 40 percent of women in the United States have dense breasts. That’s 15 million to 17 million females today. Source: Stomper PC, D’Souza DJ, DiNitto PA, Arredondo MA. Analysis of parenchymal density on mammograms in 1,353 women 25-79 years old. AJR Am J Roentgenol. 1996;167(5):1261-1265.

• Connecticut law now requires for breast density to be reported to patients after a mammography. Additional legislation has been submitted in Illinois, Florida, New York, Texas, California, Kansas, Missouri, Kentucky, and is being drafted in the U.S. House.

Sobering Facts for Women With Dense Breasts

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Alliance’s Value Proposition

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Referring physicianorders mammogramReferring physicianorders mammogram

Mammographycenter acquires

patient data

Mammographycenter acquires

patient data

Tablet in mammocenter acquires

risk data

Tablet in mammocenter acquires

risk data

Mammographicstudy performedMammographicstudy performed

Radiologist reads caseRadiologist reads case

Comprehensive Patient Evaluation

Creates reportCreates report

Acquire pathology report

Acquire pathology report

Patient navigatorcoordinates data

collectionand transmission

Patient navigatorcoordinates data

collectionand transmission

Central datarepository

Central datarepository

Breast healthnavigator or

patientcoordinator

Breast healthnavigator or

patientcoordinator

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Pathology reports include such diagnosis as hyperplasiaPathology reports include such diagnosis as hyperplasia

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

Advanced ImagingU/S, BMRI

Advanced ImagingU/S, BMRI

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Referring physicianorders mammogramReferring physicianorders mammogram

Mammographycenter acquires

patient data

Mammographycenter acquires

patient data

Tablet in mammocenter acquires

risk data

Tablet in mammocenter acquires

risk data

Mammographicstudy performedMammographicstudy performed

Radiologist reads caseRadiologist reads case

Comprehensive Patient Evaluation

Creates reportCreates report

Acquire pathology report

Acquire pathology report

Patient navigatorcoordinates data

collectionand transmission

Patient navigatorcoordinates data

collectionand transmission

Central datarepository

Central datarepository

Pathology reports include such diagnosis as hyperplasiaPathology reports include such diagnosis as hyperplasia

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Loss Leader – Low Margin Side of the Business

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Breast healthnavigator or

patientcoordinator

Breast healthnavigator or

patientcoordinator

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

Advanced ImagingU/S, BMRI

Advanced ImagingU/S, BMRI

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Risk assessment and consults lead to advanced imaging

Referring physicianorders mammogramReferring physicianorders mammogram

Mammographycenter acquires

patient data

Mammographycenter acquires

patient data

Tablet in mammocenter acquires

risk data

Tablet in mammocenter acquires

risk data

Mammographicstudy performedMammographicstudy performed

Radiologist reads caseRadiologist reads case

Comprehensive Patient Evaluation

Creates reportCreates report

Acquire pathology report

Acquire pathology report

Patient navigatorcoordinates data

collectionand transmission

Patient navigatorcoordinates data

collectionand transmission

Central datarepository

Central datarepository

Pathology reports include such diagnosis as hyperplasiaPathology reports include such diagnosis as hyperplasia

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Breast healthnavigator or

patientcoordinator

Breast healthnavigator or

patientcoordinator

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

Advanced ImagingU/S, BMRI

Advanced ImagingU/S, BMRI

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Higher-Margin Business

Referring physicianorders mammogramReferring physicianorders mammogram

Mammographycenter acquires

patient data

Mammographycenter acquires

patient data

Tablet in mammocenter acquires

risk data

Tablet in mammocenter acquires

risk data

Mammographicstudy performedMammographicstudy performed

Radiologist reads caseRadiologist reads case

Comprehensive Patient Evaluation

Creates reportCreates report

Acquire pathology report

Acquire pathology report

Patient navigatorcoordinates data

collectionand transmission

Patient navigatorcoordinates data

collectionand transmission

Central datarepository

Central datarepository

Pathology reports include such diagnosis as hyperplasiaPathology reports include such diagnosis as hyperplasia

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia (or “hypergenesis”) is a general term referring to the proliferation of cells within an organ or tissue beyond that which is ordinarily seen

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Hyperplasia qualifies for ongoing BMRIs because of risk, and is not part of Tyrer-Cuzick

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Surgeon reviews patientdata, radiological report, risk assessment, and pathology report to make a complete assessment and recommendation to primary physician

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

Dense breast evaluation is not typically done today – represents 5-6 million women not included in Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

5.6% of mammography patients would qualify for BMRI using Tyrer-Cuzick model

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Many radiologists today provide inconclusive reads,transferring the liability to referring physician or surgeon

Breast healthnavigator or

patientcoordinator

Breast healthnavigator or

patientcoordinator OR surgeon assumes

responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

OR surgeon assumes responsibility for patient care. Can perform ultrasound for dense breast , obtain pre-authorizations for treatment, return final disposition to referring physician

Advanced ImagingU/S, BMRI

Advanced ImagingU/S, BMRI

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1) Comprehensive, turnkey program• Management• Technology• Staffing• Processes• MQSA Center of Excellence• Measurements and outcomes• Patient and referring physician satisfaction

2) IT tools and enhanced workflow• MIS/RIS/PACS• Priors, Integration

Top 10 Benefits of Partnering With Alliance

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3) Complete risk assessment program• Dedicated tools/IT solutions• Integration/support infrastructure

4) Breast density evaluation• Quantitative tool

5) Patient coordinator on front end (screening)• Dense breast consult – options, referring physician interface• Risk assessment – possible genetic testing• Pre-certifications/insurance• Central database

Top 10 Benefits of Partnering With Alliance (cont.)

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6) Breast health navigator program (after diagnosis)• Patient management• Specialty interface

7) Referring physician education and training• Dedicated marketing representative

8) Professional services from Radiology 24/7, an Alliance Imaging business• Dedicated mammography and breast MRI sub-specialty reads• Physician champion

Top 10 Benefits of Partnering With Alliance (cont.)

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9) Measurements• Volume• Advanced imaging procedures• Biopsies• Consults• Diagnosis to treatment• Outcomes

10) Capital partner• Access to capital• Professional deployment of capital

Top 10 Benefits of Partnering With Alliance (cont.)

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The information contained in this document is provided on an “as is” basis without any warranties, and may not be relied upon for future results. Alliance HealthCare Services does not guarantee any financial or other performance results, which are subject to a number of uncontrollable conditions such as the market. Please consult with your own financial advisor. Results from case studies are not predictive of results in other cases; results in other cases may vary. Additionally, any marketing performed by Alliance HealthCare Services is consistent with all applicable federal and state laws, is educational in nature, and does not include any inducement or compensation for the referral of patients or business.

 Copyright 2011 Alliance HealthCare Services. All rights reserved.

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